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BOX 27
03382
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03382
OWNER'S NAME i S ` tv PHONE .
SITE LOCATION
MAILING ADDRESS
PERSON INTERVIEWED
DATE ' -7 1 oC.
PROPOSED INSTALLER
In r->
. , -PCHD .Complaint #
(i.e, owner,tenant, etc.) '
TYPE FACILITY q7
> - PHONE
v
Proposal (include sketch locating -all adjacent wells):
NOTE:. Repair must be in same location and of same type as original sewage disposal system.
Different location may require submittal of proposal.fran licensed professional engineer or .
registered architect. oUtE
� � ► � � A
Inspector's Signa
tle
PUTNAM COUNTY
WuHealth�ervices
;a i Gannmu
Carmel, ICY , 1A512
h'
/0W
Date
Proposal approved with the following conditions:
1. Procurement of any Town permit, if applicable.
2. Submission of as built repair sketch in duplicate showing:
a. Owner's name..
b. Site Street Name, Town.and Tax Map number.
c. Location of installed components tied to two fixed points (e.g.,house corners).
d. System description (e.g., 1250 gal. concrete septic tank, three precast 6' diam.,x 6' deep
drywells surrounded by one foot + gravel).
e. Installer's name and number.
3. System repair to be r o7of in accordance.with the above proposal and conditions.
.is owner, or reported a nt owner agree to the 6b6ve• conditions.
SIGNA _ _ ` TITLE DATE
PIES: Hhie (PCID); Yellcw (T:kn BI); Pink .(AnAiamt) : K
l✓��
on
h
bi
BuUding Type
I Ot o n
IF,+,,certify I t1hpz
'in'
I attached) wand Date `
4"
Any _person :occu
'.subjijct Ao4 moil if
Dates
zG
rp
above
et
rdance` with
n
A:
s.
"Address
J�
71
y se
ices
040 - d 4,5 d'4 t4
-447,e. 506-C. 7.6
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Of MA L RJ
— - - - - - - - - - -
DIVISION OF
N-Ni M T A L HEALTH Ml=,,, 4
57
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Of MA L RJ
— - - - - - - - - - -
DIVISION OF
N-Ni M T A L HEALTH Ml=,,, 4
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5,
011
X
..Owner or Purchaser of building ltnicipality .
C, J
Building Constructed by :.�Section.
Location -.Street Block
Building* Type Lot
SEPA -SYSTEM
GUARANTY .Or RATE'SEWAGE
Z
ent' that "III: �.'e'
...repres am wholly an P pops i6_1,e. for: the location,
s- �ruic ti o n,!,-.'and'.'drain age o... e sewa
workmanship - material c8n' P sewage disposal system'
. I I 1 1. .9
e describe ha 'been'constructed.,as.-shbwn of
serving :id.':,prope. 's
.,�the approve'd:planor approved aimehdMpnt:.,thereto and,.,in accordance with the standards,
regulations oun't�y�-.-te p . artment."'o*f Health, and herebv.guarz:ihty
rules and . kulat�6ns*6f�,.the: Putn
to the o'w'nerl,':.. his. ::s'u'cce.ss�Or s. h -good*qperating condition
heirs assigns;; to` place' in.
any' . part o . P: said i�;Vsie�m . - constructed ! '`b 'h' h fails to op . rate for a period of two.
me:.w ic a
years immediately following .the. datd..-O:f initial use- of the 'sewage 'disposal, system, or
,
a6 repqirs,.mdae :b
y me.to.'such sys em, exeept:where.,"the failure to J operate properly
s caused by'. the, willful .,or negligep,t act. of'the�occupant of,'the building operate`
C3
The undersigned fu*rther agrees*to accept.as conclusive the determination
of the Dire'C to - r.':*Of, the 'Division of Environmental 'Health'. Services, of . the Putnam County
t'bf' Health? failure pf e
--DegartT�en- 'the system to-operate .was
en f tilizing-t e
caused..by:the will. ul -or negligent act o the occupant, the building. utilizing h
system.:
,,.Dated this day o f
General. Contr6ctoA-.
Signature. 'Title
Septic Contractor (if corporation, give name and address
-------------------
---------------------------- -------------- -------------
THREE (3) -COPIES.-ARE REQUIRED WITH THREE -.(3.) COPIES OF FINAL PLANS BEFORE RE CERTIFICATE-
OF COMPLETION WILL BE ISSUED.
GUARANTOR IS RE UIRED TO FILE NOTICE,:'-OF DATE OF FIRST USE OF SYSTEM.
-------------------------- ----------------- 7--, - - - - - - - -- ------------------------
.Division of•Environmental.-'H6alth Services"Tutham County. Department of Health
PEEKSKILL MEDICAL. LABORATORY.
1879 Crompond Rd. Baiclay Plaza Bldg. A, Apt. 1,
40( 4r,
RESULTS OF EXAMINATION OF WATER
OWNER
Val Pete Construction Co,.Grandview Ave., Ardsley 1/4/74
CITY, VILLAGE, TOWN VOR NAME OF SUPPLY DATE REPORTED
Lot#11. Block 8. TM 6 Boswell'Subdivisio'n 0/74.
SAMPLING POINT
BACTERIA PER ML. (Agar plate count at 350C).
8
COLIFORM GROUP (Most pro9391—eN6..,/I00mI.)
less than 202
HARDNESS, TOTAL mppm
DETERGENTS= ppm
NITRATES (as N) - pOm
IRON, TOTAL - ppm.
FLOURIDE (F) - mg./I.
These results indicate that the water was yes of a satisfactory sanitary quality when thd sample was colle
A. H. PADOVANI, M. T. (ASCP)
Weeaehee6sr County Department of Health
Division of Environmental Sanitation
This report is to be completed by well driller and submitted to Health Department, together with
laboratory report of analysis of water.sample indicating water is of satisfactory bacterial
quality, before certificate of construction compliance is issued,'
Well construction to be in accordance with Bulletin SD-62
*RULES & REGULATIONS RELATING TO INDIVIDUAL WATER SUPPLIES"
LOCATION: KUNIC ALITY T C. S BLOCK I ��
UM OWNERs 1141 fel-*e,611el
Rams/ /`_ /. Street 'Address City and Town �
HELL DRILLERS Cl �/D / /•i�s.,f��d �r/� /e �!�'e. d/ 0� /Y,
f:
I Bailed t(measure from land surface)
LenithS Feet' or I I
7-x' t � Pumped 1� Hours 'Static: I Feet I Make:
en Bailed I Islot
Di er: Inches tiield: 07� G.P. I. t or Pumped J7,J Feet t Length Ft. rSize
� S
XW, Diameter In.'
TOTAL DEPTH OF WELL FEET
GiV ®wdeecxtiocl :4'ormstiods : netrated� such ass
Ground Surface � o hard � � ' Pest`, eil't,. eeadi.�gra�el; ;
lay, pan, •shale, sandstone, granite, eta. Include size of gravel (diameter,
and sand.(fine, medium, coarse), color of material, structure (Loose, packed,
cemented, soft, hard). For example: 0 !t. to 27 ft, line, packed, yellow sand;
�. 27 !t. to 131. ftg gray granite.
D Ft.bo %y` Ft. t g i xo ^#/V1 .
A4 n.to J/ Ft, i eSi0/YU
I i-,/ w /'A& / �ac/'ae-.c.r
e ,
37 J- n,to 4a. Ft. c e / v crK
n.to Ft.
t
n.to
Date Well Was Completed 2L� Date of Report 49 7 3
Well Driller
Signature
WELL PIT AND PUMP EQUIPMEMT DETAILS
I fl$ofleh�i9' ���s Cfieck
Pit with 4—inch Gravity Drain to Basement
Pitless Adaptor A Casing ilno 12 inches abodo grade
Others Describe
Paps MalrA Type Capacity G. P.M, �.
3tarego `hanks Types Capacity G&J, (42 Gail, Xino )
DIAGRAM[ SHOWING IXATION OF WELL ON PRMSES
Indicate location of house, well and
sewage disposal system with distances,
Also indicate direction of slopesD aid
direction with distances to all wells
and sewage disposal systems within 250 ffoeto
!N41. bl
h
0�
I certify that the individual water supply indicated above eras installed as per the
$aloe and regulatiow of Bulletin SD,62 of the Westchester County Department of Healtho
G
K.
ILE) $ # �
FIE ,D CIr K
LIST
l
Dat
n;
Insp.by:
D I�Woi
TNTTTATr
STZ'E Ir'rSPFCTIOId
iYes
No
Comments
Property lines or corners found a . . .
Can estimate house location . . 0 0 C . .
Will driveway need cut . , .
Must trees be removed -note these. o . 0 0. .
Is deep hole representative of entire SDS area
Additional deep holes needed. . Y C .
Sufficient SDS area available considering.
driveway cut,house location,separation
distances, etc. . . o . . . . . . . . o
DEEP HOLE DATA `
Depth: 7'
Water elevation:
Rock elevation:
Soils description: z," TS. S'C-A tl-61
Date:
J
FINAL SITE INSPECTION Ins p. b
House located where shown on approved plan. o o.
_BOSS loea,ted where arpro eft . ... o
f.-- !f }v.r i t•, r' r.r�rri. :. .ru =.;. ". -r T'C-'r l .. - }
Width of trench average
Slope of the line and trench acceptable . , .
Room allowed for expansion trenches. ,
5.O -f,t,. •. from.,.swamp. w t�erc:ou�-se ,.:.., -.
-
7 Nat--+ urd-1 - s•oi!7 -not -stir pp °d`' or" SIDS
unnecessarily graded
.10 Ft. maintained.from prop line acid
20 ft. from house
Separation of trench from house., well
etc . follows plan . . . o . 0. a a
Number . of bedrooms . checks e o . o e
Stones, brush, stumps, rubble., etc greater
than 15 ft. from nearest trench:'
rench � . o
15 Ft. of peripheral soil horizontally,from
trench . . . 9 e. a 4. u 0.6 0 G .O o
Junction boxes p r ope-ly set
Gould - surface run of from driveway, . roads.,
ground surface, etc. channel near SDS
area . . . . o
Does'l.ot, drainage appear O.K. in area of..SDS
FINAL GRADING OF SITE..ACCEPTABLE
.i
f .
.i
77
T'
,
- -_ ---• - - -_ t . .__... PUTNAM COUNTY DEPARTMENT OF HEALTH
DIVISION OF ENVIRONMENTAL HEALTH SERVICES
COUNTY OFFICE BUILDING, CARMEL, N. Y. 10512
DESIGN DATA SHEET-SEPARATE SEWAGE DISPOSAL SYSTEM FILE NO.
Owner ooA ` 1' eft. Co, Address C,�m� YA
Located at (Street ennAp_ ec. 62- Block Lot
n lca e Lea es oss street)
Municipality— rU-) ,jg M
SOIL PERCOLATION TEST DATA
Watershed CM A-1Z r .
TO BE SUBMITTED WITH APPLICATIONS
Hole
Number CLOCK TIME PERCOLATION PERCOLATION
Elapse Dep o Water Water ve
No. Time From Ground Surface in Inches Soil Rate
Start -Stop Min. Start Stop Drop in Min. /in drop
Inches Inches Inches
1
3 P, S5 W, oo _5 19-
51(,nG I C..' 2,0
2
3
4,
5
Notes: 1) Te'gts to be repeated at same depth until aroximatelyy equal soil
rates are obtained at each percolation test hole. All pp data to be submitted
for review.
2) Depth measurements to be made from top of hole.
t
o Y>
i
TESS_�IT_,DATA.. R .QUIRFD TO-.BE..,. SUBMITTED. WITH- ,AFPLI.CAT1QN,, `,—
CRIPTI'ON- OE SOILS isNCOUN'I'tllD IN TEST'`ROMS
DEPTH HOLE N0: HOLE NO. HOLE NO.
G. L. y
1211
1811
24"
30"
36
421t
>
4811
5411
6011
66"
7211
7811
if
84
T�TDI TE L ]AT� VIHICH GROUND WATER iSW-E1VC0UNTERED _- ..
INDICATE LEVEL TO WHICH ATER TEVEL RISES ER BEING ENCOUNTERED
TESTS MADE BY Date 7
DESIGN
Soil Rate Used 10 Min/l "Drop: S.D. Usable Area Provided S- o -,-e,S
No. of Bedrooms Septic Tank Capacity Gals,_ Type _
Absorption Area Provided By gao L.F.x24 -- wL--dth trench.
ES ^�
Address
THIS SPACE FOR USE BY HEALTH -MPARTP /NZ
Soil Rate Approved Sq. Ft/Gal.
of
Q� A! KE q<
Ere w. 7 4; f"
SEAL o ;:,:_. g i
ONLY: CS, _' •" %/
Checked by Date
REVIEW CHECK SHIMT P- L5eMso n O cat") 6, l9 73
,ee.ts Std.! Remarks
SEPARATION DISTANCES SPECIFIED ON PLAY
10'
to
P. L.
✓
I
DOCUMENTS
to
Foundation walls i
✓
House- plans, O:K..� _. .. - -. - . � - -.. - . . .. .. ......._ .. -
. ✓
00'
-
Design data sheet
!
50'
Peres presoaked?
i
i ;
r
Min. 30". perc test depth
j
Curtain drain
Const. results -. for. 3 runs
! ✓
water line (pits -20' ). !
j
D.`Hole.log.O.K.
to
storm drain
Corporate_ Affidavit for other than individual
;/
,r
!
Authorization for erigineer
! V
I
Letter from Wate..r Supply if applicable
!
to
_
If variance requested -such noted on plans & apps.:
!
_
j
DETAILS_
if chaing is proposed.)
Existing contours shown show new contours)
Slopes -for driveway cuts shown
Water service line location
.r
f
Footing.drain,'etc. location
I
Top "slope, bottom slope of fill
I
L-
I NO Fill
'Percolation -tests and deep test pit location
; ✓ 1'i
Septic tank size and•conformance to std. _.
3 'B..R. house :minimum
f ✓
f
House setback shown
I ✓ j
1111 aia �ei w iul >v i . u i r.0 suuwil
t
............
Plan and profile SDS
_
All other wells and SDS closer 200'
shown.. or referenc ,e_,ma.aq,,.__.:- :..::._
:..:...._.._...._r:_,._-..:....:-
- • Prop✓z t � bo- unaares
y (m„ tes ana _fiounds cli. drly
shown
i
-
SEPARATION DISTANCES SPECIFIED ON PLAY
10'
to
P. L.
✓
I
20'
to
Foundation walls i
✓
I I
00'
to
Nearest well !�
I
50'
to
stream, march, lake,.etc. incl.expansion ;
i ;
r
15'
to
Curtain drain
10'
to
water line (pits -20' ). !
✓ l 1
15'
to
storm drain
10'
to
large trees I
i
from foundation to septic tank !
i
110'
5'
to
pipe from leader drain & footing drain
64p h(- &n o . 5 ij q a 1 ?0� W L too
t anti fru,y, �O i B� �d�ovec( �, Su b
o�v waK tors' a . rju-4.
I
D
Re: Property of
Located at��-��
Section (n 7- Block Lot
Gentlemen:
This letter is to authorize w II
a duly, licensed.professional engineer or registered architec
.(Indicate)—
to apply' fpr,'a Construction Permit fora separate sewerage system; to
serve ;tie above noted property in accordance with the standards, rules
or regulations as promulgateJ..by the Commissioner of the Putnam County
Department Gi HeaiVll, an Vo sIgi till neuessary papers on my behalf in
,..'.;`�: "connection with this matter and to supervise the construction of said
F -. system- 9r.ysy.s_tems in..conformity.-_with..the. grn visions „_,of_ -Article._,145.or.
5 a:`. -,. ::•: t •-:,-. -.. -_:. -, ... . _. -- 7•.... .,.a .._. .. -ter. -..e .-,. <, .!l , ,r .--.. .. F -- - •�.•
Education Law, the Public Health Law, and the Putnam County Sani-
tary Code.
01A. K
Signed / ��
_ __ ._ .......__.. _ _ y
pLAN
- �`; • t =aft,`? �.- �--'" ;:�,._M�f T : -�„
111 2t. 74 :ox F ?4
j p• `0 �'"'" Sf--r,� 1--i.- u
�--�
��' `�y k +G i flo..s. ✓ � .. �1 � ,F 4'��Fk L j �_ —_
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s- DS
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nottt <<: y } ,{ OCTZ3 1973_. goo.
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